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 Table of Contents  
REVIEW ARTICLE
Year : 2020  |  Volume : 12  |  Issue : 3  |  Page : 223-233  

The early mortality rate of people infected with coronavirus (COVID-2019) in Wuhan, China: Review of three retrospective studies


1 Pharmacy Practice, College of Pharmacy, Gulf Medical University, Ajman, UAE
2 College of Pharmacy, Gulf Medical University, Ajman, UAE
3 Clinical Pharmacist, Omdurman Islamic University, Omdurman, Sudan
4 Department of Epidemiology and Population Health, Khalifa University, Abu Dhabi, UAE
5 Ambulatory Healthcare Services, Academic Affairs, Abu Dhabi Health Services (SEHA), Abu Dhabi, UAE
6 Department of Clinical Pharmacy, College of Pharmacy, Taif University, Riyadh, Saudi Arabia
7 Department of Pharmacist, College of Pharmacy, Khartoum University, Khartoum, Sudan
8 Clinical pharmacy, College of Pharmacy, Riyadh Elm University, Riyadh, Saudi Arabia
9 Dentist, MySmile Dental Clinic, Dubai, UAE
10 Assistant Professor, Program of Clinical Pharmacy, College of Pharmacy, Al Ain University, Al Ain, UAE

Date of Submission19-Apr-2020
Date of Decision29-Apr-2020
Date of Acceptance12-Jun-2020
Date of Web Publication20-Jul-2020

Correspondence Address:
Prof. Asim Ahmed Elnour
Pharmacy Practice, College of Pharmacy, Gulf Medical University, Ajman.
UAE
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/jpbs.JPBS_282_20

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   Abstract 

Background: The infection with coronavirus and non-survivor cases have been escalated since the first inception between January and March 2020. Therefore, reviewing the collated clinical characteristics of non-survivors might assist in current preventive efforts, triaging, and management of survivors. The aim of this review was to summarize the clinical characteristics of non-survivor cases due to the infection caused by a novel coronavirus and to identify the relevant data that might put the new cases at increased mortality. Materials and Methods: We have identified three published articles on novel coronavirus reported during December 01, 2019, to March 15, 2020, which have described the mortality rate in Wuhan, Hubei, China. Results: The mean duration of studies (i.e., the three retrospective studies with 278 cases) was 24.7 days, and the duration of onset to dyspnea was variable between 8 and 5 days. The main reported complications were acute respiratory distress, pneumonia, acute kidney injury, and acute cardiac disease. The overall major comorbidity reported was cardiovascular diseases at 23.7% (66 of 278). The reported overall mortality rate was 8.3% (23 of 278), with the highest mortality rate of 15.0% (6 of 41) reported in Jin Yintan Hospital at Wuhan city. Conclusions: The clinical characteristics of the non-survivors from the novel coronavirus included adult males, aged older than 50 years, having comorbidities of cardiovascular disease, respiratory distress syndrome, acute kidney injury, and diabetes with higher admission to the intensive care unit. The mortality rate was high in two of the reported studies (15.0% and 11.0%), which was decreased in the later-dated study to 3.4%.

Keywords: Coronavirus, coronavirus disease, non-survivors, novel coronavirus pneumonia, Wuhan


How to cite this article:
Elnour AA, Don J, Yousif I, Gnana K, Abdi S, Al Hajri N, Al Amoodi A, Fathelrahman AI, Magboul SM, Mohamed S, Ahmed SA, Sadeq A. The early mortality rate of people infected with coronavirus (COVID-2019) in Wuhan, China: Review of three retrospective studies. J Pharm Bioall Sci 2020;12:223-33

How to cite this URL:
Elnour AA, Don J, Yousif I, Gnana K, Abdi S, Al Hajri N, Al Amoodi A, Fathelrahman AI, Magboul SM, Mohamed S, Ahmed SA, Sadeq A. The early mortality rate of people infected with coronavirus (COVID-2019) in Wuhan, China: Review of three retrospective studies. J Pharm Bioall Sci [serial online] 2020 [cited 2020 Oct 28];12:223-33. Available from: https://www.jpbsonline.org/text.asp?2020/12/3/223/290123




   Introduction Top


The city of Wuhan is considered the political, economic, financial, commercial, cultural, and educational center of central China.[1] Wuhan-origin novel coronavirus or coronavirus disease (2019-nCoV/COVID-19) was first time reported as an outbreak of atypical pneumonia in December 2019, at the city of Wuhan, capital of Hubei province, China (350 research institutes, Wuhan University was ranked third nationwide in 2017). The full-genome sequencing indicated that 2019-nCoV is a distinct clade from the β-coronaviruses associated with human severe acute respiratory syndrome (SARS) and Middle East respiratory syndrome (MERS).[2]

The 2019-nCoV has been identified as a novel type of coronaviruses that is transmitted between humanto-human (via droplets or direct contact) hosted from infected animals, seafood, or possibly bats. The trade on live animal, wet market, and the food system in the Wuhan city deserves a closer look to investigate the mode of transmission of the virus and the association with human and to rule out any rhetoric prejudged associations. The available current evidence suggests the transmission of 2019-nCoV to human was from wild animals illegally sold in the Huanan Seafood Wholesale Market. The presence of 2019-nCoV in the bronchoalveolar lavage fluid of a subject in Wuhan was reported and was confirmed as the cause of 2019-nCoV-infected pneumonia. It has been reported earlier that bats were the natural reservoir host of 24 respiratory syndrome–related coronaviruses (SARSr-CoV).[3],[4],[5],[6]

The first identification of infection with 2019-nCoV was dated back to December 12–19, 2019. On January 20, 2020, 198 infected cases were confirmed by laboratory tests with three fatal cases. The case reports have confirmed that 2019-nCoV-infected pneumonia was transmitted human to human.[7],[8]

The global efforts continue to quash the pandemic, with high responsibility and high response to the emergency situations. In line with the global efforts, this review aims mainly to delve deeper into the characteristics of non-survivors to assist healthcare professionals in triaging high-risk subjects to prompted care and timely interventions.

The objective of this review was to collate and report the published data on the mortality rate from 2019-nCoV and to highlight the main findings with the most updated information from reliable literature resources.


   Aim of the Review Top


The main aim of this review was to objectively summarize the clinical characteristics of non-survivor cases with 2019-nCoV and to identify the relevant data that might place the critically ill patients or survivors at increased mortality risk.


   Rational Top


The infection with coronavirus (2019-nCoV or COVID-19) and non-survivor cases have been escalated since the first inception between December 12 and 19, 2020. Therefore, reviewing the collated published articles and systematically evaluating the clinical characteristics of non-survivors might assist in current preventive efforts, triaging, and management of survivors and new cases.


   Materials and Methods Top


The published studies on 2019-nCoV mortality rate reported from December 01 to February 29, 2020 were retrieved from Google Scholar, MEDLINE, and journals such as The Lancet and the New England Journal of Medicine. We have included the articles published in the English language, which have described the clinical characteristics of non-survivors (mortality rate) in Wuhan/Hubei, China, using the following MeSH terms: China, Coronavirus, COVID-19, novel Coronavirus (2019-nCoV), death, infection, mortality rate, pneumonia, survivors/non-survivors, and Wuhan.

We have reviewed published articles of studies conducted in Wuhan city, China during the period between January 2020 and February 29, 2020. We have included the studies (retrospective) conducted in Wuhan hospitals, published in English, and those reporting mortality rates. We have excluded case studies and case series studies and case–control studies. Initially, we have screened seven studies, where three studies[9],[10],[11] were eligible as per our inclusion criteria and four studies were excluded with reasons.[12],[13],[14],[15] The first excluded cross-sectional study comprised data for cases from other regions in Hubei Province, that is, from Xiangyang, the second biggest city in Hubei with a large number of labor force migrant to Wuhan. The second excluded retrospective study was conducted on a sample of critically ill subjects drawn from 710 admitted cases. The third study was a case series study for laboratory findings without a reported mortality rate. The fourth excluded retrospective study was on laboratory data (laboratory-confirmed Covid-19 from 552 hospitals in 30 provinces) [Table 1] and [Table 2].
Table 1: The details of studies included and the mortality rate reported from Wuhan city, Hubei Province (23/278, 8.3%)

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Table 2: The details of studies excluded with reasons

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Statistical analysis

There were no statistical tests performed as we have relied on reported data and comparison of published mortality rates between studies.

Outcome data

The outcome events or summary measures were presented as the percentage of mortality rates.


   Results Top


The mean duration of studies (i.e., the three retrospective studies with 278 cases)[9],[10],[11] was 24.7 days, and the duration of onset to dyspnea was variable between 8 and 5 days;[9],[11] however, it was not reported in the study of Chen et al.[10] The median hospital stay was 10 days (interquartile range [IQR], 7.0–14.0) as reported by Wang et al.[11] The mean duration of time from the first symptom to the date of hospitalization was 5.7 days. The mean duration of time in the intensive care unit (ICU) was 8.2 days [Table 3]. The main reported complications were acute respiratory distress syndrome (ARDS) (not reported in the study of Wang et al.[11]), pneumonia, acute kidney injury, and acute cardiac disease [Table 3].
Table 3: The time/duration (study duration, duration of onset to dyspnea, hospitalization, time from the first symptom to the date of hospitalization, ICU admission, and death), complications, and total mortality

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The overall major preexisting medical conditions (comorbidities) reported by the three studies in a descending pattern were cardiovascular diseases, diabetes, cancer, chronic respiratory diseases, and chronic liver disease. The highest comorbidities reported were cardiovascular diseases at 23.7% (66 of 278) [Table 4].
Table 4: The preexisting medical conditions (comorbidities) of the subjects in the three reviewed studies

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The major reported symptoms/signs of the cohorts were fever, cough, dyspnea, myalgia/fatigue, and respiratory distress syndrome and highly reported admission to the ICU. The most commonly prevailing symptom in the reviewed studies was fever in nearly all cases: 98.0%, 82.0%, and 98.6%, respectively, in the three compared studies.[9],[10],[11] The respiratory distress syndrome was reported in 29.0%, 17.0%, and 19.6% of patients, respectively, in the three studies. A high incidence of diarrhea was reported in 10.1% (14) patients by Wang et al.[11] Dyspnea was prevailing in 55.0% of the cases reported by Huang et al.[9] Cough was reported in 82.0% of the cases studied by Chen et al.[10] Myalgia was highly reported in 44.0% of the cases studied by Huang et al.,[9] whereas nausea was highly reported by Wang et al.[11] Organ failure was reported in 26.1% of the cases by Wang et al.[11] The highest number of cases (32.0%) admitted to ICU was reported by Huang et al.[9] Overall 25.9% (72 of 278) of cases with 2019-nCov had pneumonia required ICU admission, detailed as 13 of 41 (31.7%), 23 of 99 (23.2%), and 36 of 138 (26.1%), respectively.[9],[10],[11] Approximately 56 (20.1%) subjects have had acute respiratory distress disease, 19 (6.8%) have had a shock, 11 (4.0%) have had acute kidney injury, and 14 (5.0%) required continuous renal replacement therapy [Table 5].
Table 5: The symptoms and signs of the subjects in the three reviewed studies (Wuhan, Hubei province)

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Initially, on January 24, the reported mortality rate of 2019-nCoV was 15.0% (6 of 41); later, on January 29 and February 7, lower mortality rates reported were 11.1% (11 of 99) and 4.3% (6 of 138), respectively.[9],[10],[11] The mean overall mortality rate was 8.3% (23 of 278). The highest mortality rate was 15.0% (6 of 41), which was reported by Huang in Jin Yintan Hospital at Wuhan city.[9] The mean duration of onset to death was 13.3 days.

The first included study was on subjects admitted to Jin Yintan Hospital in Wuhan, whereby the investigators have collected and analyzed data from electronic medical records of 41 subjects with laboratory-confirmed 2019-nCoV infection by real-time polymerase chain reaction (RT-PCR) and next-generation sequencing. The majority of cases were men (30 [73.0%]) with the median age of 49.0 years (IQR, 41.0–58.0). Of overall 41 cases, 13 (32.0%) were admitted to the ICU and 6 were non-survivors (15.0%).[9]

In another retrospective, single-center study, 99 cases of 2019-nCoV were confirmed by RT-PCR and were analyzed for epidemiological, demographic, clinical, and radiological features and laboratory data in Jin Yintan Hospital, Wuhan. The average age of the subjects was 55.5 years (standard deviation [SD], 13.1), including 67 men and 32 women. The presence of 2019-nCoV was confirmed in all subjects by RT-PCR. The health condition of 11 (11.1%) patients worsened in a short period, and they died of multiple organ failure.[10]

The largest retrospective, single-center case series has reported 138 consecutive hospitalized cases with confirmed 2019-nCoV-infected pneumonia at Zhongnan Hospital of Wuhan University in Wuhan, China. The median age was 56 years (IQR, 42–68; range, 22–92 years) with slightly more than half were males (54.3%). The study reported an overall mortality rate of 4.3% (n = 6).[11]

Mortality data comparison: The world data from the John Hopkins dashboard (https://gisanddata.maps.arcgis.com/apps/opsdashboard/index.htm1#/bda7594740fd40299423467b48e9ecf6) have reported 24 h follow-up of the global pandemic of infected 2019-nCoV. As of March 13, 137,445 cases were reported worldwide with 69,779 (50.1%) recovered and 5,081 non-survivors with an overall mortality rate of 3.7%. Of the total global cases, 80,945 cases were reported in China mainland, 64,194 (79.3%) cases recovered, and 3,180 non-survivors with an overall mortality rate of 3.8%. The major reported confirmed cases in Wuhan city (Hubei mainland) were 67,781 (83.7%) with 51,553 (76%) recovered cases and 3,056 non-survivors (mortality rate of 3.7%).

As of March 13, 2020, strikingly more cases were reported in Italy (n = 15,113), with low recovery rate of 6.9% (n = 1,045) and the globally highest mortality rate of 6.7% (n = 1,016). The highest recovery rate of 26.0% (n = 2959) was reported in Iran of 11,364 infected cases, and the second highest mortality rate of 4.5% (514) worldwide outside China mainland. South Korea has reported 7,979 cases, 510 (6.4%) recovered, and 66 non-survivors (lowest mortality rate of 0.8%) among the highly infected countries (China, Italy, and Iran) [Table 6]; [Figure 1][Figure 2][Figure 3].
Table 6: The global mortality rate as per the John Hopkins website (as of March 13, 2020)

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Figure 1: Frequency and the respective percentage of the confirmed infected cases per country (global cases 178,508 [100.0%])

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Figure 2: Frequency and the respective percentage of the non-survivor cases per country (global cases 178,508 [100.0%])

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Figure 3: Frequency and the respective percentage of the recovered cases per country (global cases 178,508 [100.0%])

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The figures were updated on March 23, 2020 [Figure 4][Figure 5][Figure 6].
Figure 4: Global distribution of frequency and the respective percentage of the confirmed infected cases per country (global cases 336,004 [100.0%]), as of 12:00 GMT, March 23, 2020. (Available from: https://www.arcgis.com/apps/opsdashboard/index.html#/bda7594740fd40299423467b48e9ecf6. [Last accessed on 2020 March 23]). We did not report cases from countries that are below 1900 confirmed cases

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Figure 5: Global distribution of frequency and the respective percentage of the non-survivor cases per country (global cases 14,641 [4.3%]), as of 12:00 GMT, March 23, 2020. (Available from: https://www.arcgis.com/apps/opsdashboard/index.html#/bda7594740fd40299423467b48e9ecf6. [Last accessed on 2020 March 23]). We did not report cases from countries that are below 1900 confirmed cases

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Figure 6: Global distribution of frequency and the respective percentage of the recovered cases per country (global cases 98,334 [29.3%]), as of 12:00 GMT, March 23, 2020. (Available from: https://www.arcgis.com/apps/opsdashboard/index.html#/bda7594740fd40299423467b48e9ecf6. [Last accessed on 2020 March 23]). We did not report cases from countries that are below 1900 confirmed cases

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   Discussion Top


We have reported the results from three retrospective studies conducted in Wuhan, China, with 278 cases admitted to Wuhan hospitals in Hubei Province, China. The main findings were the reported overall mortality rate of 8.3% with the duration of 13.3 days from onset to death. The globally reported mortality rate was 3.7% (126,000 of 4,600) as of March 12, 2020, increased by 0.2% than the previous day. There was a huge surge in the globally reported new cases (outside China mainland) during the last few days from March 9 to 12, 2020, from 115,000 to 118,000 to 125,000 cases as per the John Hopkins dashboard.[16]

The whole China mortality rate was 3.8% (80,101 of 3,136), whereas the Wuhan reported mortality rate was 3.9% (80,929 of 3,172). However, we have observed a high mean mortality rate of 8.3% in this review of the three studies. Further low mortality rates of 2.4% (1,018 of 43,112), 3.7% (4,600 of 126,000), and 3.7% (5,081 of 137,445) were reported at an online dashboard (Johns Hopkins Center for Systems Science and Engineering), as of February 11, March 12, and March 13, 2020, respectively.[16] The reported mortalities rates were low compared with the mortality rates of 9.5% and 34.4% for SARS and MERS, respectively.[17] However, the number of infected persons with 2019-nCoV surpasses that of SARS and MERS.[18]

In a medical record retrospective study conducted in Renmin Hospital of Wuhan University (from January 14 to February 13, 2020), the mean age was 71.48 ± 12.42 years and the duration of the disease was 10.56 ± 4.42. The authors have reviewed 59,883 cases to identify the clinical characteristics of the non-survivors with COVID-2019. The 25 non-survivor cases have tested positive for severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) by the use of RT-PCR on samples obtained from their respiratory tract (throat swab). The authors have reviewed the clinical records, laboratory and radiological findings of 25 non-survivor cases and have revealed that the non-survivors were having pneumonia caused by COVID-19 and have died due to respiratory failure, shadowed by multiple organ failure. The most significantly associated comorbidities were hypertension 64% (16 of 25), followed by diabetes 40% (10 of 25), heart diseases 32% (8 of 25), and kidney diseases 20% (5 of 25). The most important risk factors for death caused by COVID-19 were age and the preexisting medical condition.[19]

The characteristics of the non-survivors in the aforementioned study were very similar to the earlier studies reported in this review. For instance, this review has similar findings in terms of the characteristics of cardiovascular comorbidities (hypertension) in non-survivors. However, the study by Li et al.[19] did not report the number of the clinical records reviewed from which the non-survivors were retrieved and has not reported any mortality rate.

The overall major preexisting medical conditions (comorbidities) reported in this review were cardiovascular diseases, diabetes, cancer, and chronic respiratory diseases, which were in line with the main clinical characteristics in the descriptive study conducted in non-survivors by Li et al.[19] The age of subjects reported in these three retrieved studies was younger than 60 years, which was far less than that reported by Li et al.[19]

Lai et al.[20], from the Department of Medicine, College of Medicine, National Cheng Kung University, Tainan, Taiwan, have reported a pooled data analysis of the same three studies reported in this review. The pooled data contain in-depth epidemiological information, laboratory data, clinical manifestation, radiological findings, and treatment options. However, our current review has compared the mortality rates between these three studies and has inferred them to the global mortality rate, Wuhan mainland mortality rate, and the newly emerging data from four highly affected countries, namely China, Italy, Iran, and South Korea.

Compared with the international mortality rate as of March 13, 2020, the mortality rate was the highest in Italy and the recovery rate was the highest in Iran. The lowest mortality rate was reported in South Korea despite the low recovery rate.

In this review, we neither found any relevant information regarding the severity of pneumonia, the use of confusion, urea, respiratory rate, blood pressure, and 65 years of age or older (CURB65) score for pneumonia grading, nor the use of the Sequential Organ Failure Assessment (SOFA) for the ICU cases. It is highly recommended to include the CURB score at the initial admission phase and SOFA at the initial intention to admit to ICU, as planned triaging, ventilation maneuvers, and treatment levels will differ accordingly.

Summary of the main findings

The main reported complications from this review of the most cited articles on 2019-nCoV were ARDS, pneumonia, acute kidney injury, and acute cardiac disease.

The overall major comorbidity reported was cardiovascular diseases at 23.7% (66 of 278). The mortality rate was high in two of the reported studies (15.0% and 11.0%), which was decreased in the later-dated study to 3.4%. The reported overall mortality was 8.3% (23 of 278), with the highest mortality rate of early reported cases 15.0% (6 of 41) at Jin Yintan Hospital in Wuhan city.

The clinical characteristics of the non-survivors from the 2019-nCoV included adult males, older than 50 years, having comorbidities of cardiovascular disease, respiratory distress syndrome, acute kidney injury, and diabetes with higher admission to ICU.

The infection with coronavirus (2019-nCoV or COVID-19) and the non-survivor cases have been escalated worldwide (e.g., Italy), whereas the recovery cases were on the rise and the mortality rate was decreasing in Wuhan and overall China mainland.

Limitations of the included studies

The study by Huang et al.[9] has reported some limitations such as the lack of serological tests to differentiate between lower and upper respiratory tract infected cases, viral kinetics, viral titer, and viral load. Furthermore, the small sample does not permit the assessment of host risk factors for disease severity and mortality with multivariate analyses to define the clinical presentation, natural history, and risk factors. There was no reporting on pediatric or adolescent subjects that raises exposure bias.[9]

The study by Chen et al.[10] has two limitations, it has ruled out suspected but undiagnosed cases in the analyses and the lack of detailed patient information, particularly regarding clinical outcomes, of 2019 nCoV pneumonia in Wuhan, China.

The study by Wang et al.[11] has reported three limitations: the lack of evaluation of serum viremia and viral load as a useful marker associated with disease severity of coronavirus infection, the lack of confirmation of hospital-related transmission of infection, and lastly, some cases were still hospitalized, which prohibit the assessment of risk factors leading to a poor outcome.

Limitations of this review

We did not have access to the individual data of cases to perform pooled analyses or subgroup analyses.


   Conclusion Top


The clinical characteristics of the non-survivors from the 2019-nCoV included adult males, older than 50 years, having comorbidities of cardiovascular disease, respiratory distress syndrome, acute kidney injury, and diabetes with higher admission to ICU. The mortality rate was high in two of the reported studies (15.0% and 11.0%), which decreased in the later-dated study to 3.4%. The information drawn from this review is of particular importance to the healthcare professionals regarding the early triaging of infected cases and risk stratification based on the severity of reported high symptoms, preexisting clinical conditions, admission to ICU, male gender, and patients older than 50 years of age.

Special attention should be directed toward the public to report any suspected cases, avoidance of traveling to highly infected areas, following good self-hygiene, and visiting the health services in case of fever, cough, and increased dyspnea.

The international community continues to implement strategies that minimized the spread of the 2019-nCov (COVID-19 or SARS-CoV-2) with regulations from the World Health Organization, the health authorities in all countries, the public, and many have joined the efforts to safeguard against the twenty-first century pandemic of the ever small dreadful virus.

The good news is always there, that the new cases reported from Wuhan are rapidly subsiding, and the recovery rate has increased, and the great efforts of the great people of Wuhan and China mainland and the great international support will soon bring back the peaceful life.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
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    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6]
 
 
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